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Emergency Medicine > TRAUMA AND ORTHOPEDICS
Plantar Fasciitis
Article Last Updated: May 29, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Deepika Singh, MD, Staff Physician, Department of Emergency Medicine, Brown University
Deepika Singh is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Nurses Association, Emergency Medicine Residents Association, and Sigma Theta Tau International
Coauthor(s):
Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn;
Leslie Milne, MD, Assistant Clinical Instructor, Department of Emergency Medicine, Harvard University School of Medicine
Editors: Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, Associate Clinical Professor; Medical and Managing Director, South Texas Poison Center, Department of Surgery/Emergency Medicine and Toxicology, University of Texas Health Science Center at San Antonio; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
plantar fasciitis, jogger's heel, tennis heel, bone spur, heel pain, pain on bottom of heel, exostosis, flat foot, highly-arched foot, excessively pronated foot, gait alteration, obesity, tight Achilles tendon,policeman's heel, pes planus, pes cavus
Background
Plantar fasciitis is the most common cause of heel pain for which professional care is sought. A variety of terms have been used to describe it including jogger's heel, tennis heel, Policeman's heel, and an outdated term, gonorrheal heel reflecting the old thought that it was somehow related to that sexually transmitted disease.
Pathophysiology
The plantar fascia originates on the medial tubercle of the calcaneus and fans out over the bottom of the foot to insert onto the proximal phalanges and the flexor tendon sheaths. It forms the longitudinal arch of the foot and functions as a shock-absorber as well an arch support. The term fasciitis may be somewhat of a misnomer since the disease is actually a degenerative process with or without inflammatory changes, which may include fibroblastic proliferation. This has been proven from biopsies of fascia from people undergoing surgery for plantar fascia release. It is commonly believed to be caused by repetitive microtrauma to the fascia.
Frequency
United States
Plantar fasciitis accounts for about 10% of runner-related injuries and 11-15% of all foot symptoms requiring professional care. It is thought to occur in 10% of the general population as well. It may present bilaterally in a third of cases.
Mortality/Morbidity
Plantar fascitis probably may lead to significant morbidity placing strict activity limitations on the patient. In addition, due to the pain in the foot leading to changes in patterns of bearing weight, associated additional injury to the hip and knee joints may also occur.
Race
Race and ethnicity play no role in the incidence of plantar fasciitis.
Sex
The condition occurs equally in both sexes in young people. Some studies show a peak incidence may occur in women aged 40-60 years.
Age
The condition can occur at any age. As mentioned, a peak incidence may occur in women aged 40-60 years.
History
- The patient reports inferior heel pain with the first few steps taken in the morning or after other long periods of nonweightbearing.
- A limp may be present, and patients may prefer to walk on their toes.
- Initially, the pain decreases with ambulation but then increases throughout the day as activity increases. Pain is worsened by walking barefoot on hard surfaces or by walking up stairs.
- Associated paresthesias, nocturnal pain, or systemic symptoms should raise suspicion of other causes of heel pain (ie, neoplastic, infectious, neurologic causes).
- Patients may report that before the onset of pain, they had increased the amount or intensity of activity including, but not limited to, running or walking. They may have also started exercising on a different type of surface, or they may have recently changed footwear.
Physical
- The patient may have tenderness upon palpation of the anteromedial aspect of the heel.
- Ankle dorsiflexion may be limited due to tightness of the Achilles tendon.
- Pain may be exacerbated by passive dorsiflexion of the toes or by having the patient stand on his or her toes.
Causes
- The cause of plantar fasciitis is unclear and may be multifactorial. Because of the high incidence in runners, it is best postulated to be caused by repetitive microtrauma. Possible risk factors include obesity, occupations requiring prolonged standing, heel spurs, pes planus (excessive pronation of the foot), and reduced dorsiflexion of the ankle.
Abdominal Pain in Elderly Persons
Bursitis
Fractures, Foot
Osteomyelitis
Reactive Arthritis
Other Problems to be Considered
Paget disease
Rupture of plantar fascia
S1 radiculopathy
Sickle cell disease
Spondyloarthropathy (ie, Reiter syndrome, ankylosing spondylitis, psoriatic arthritis)
Tarsal tunnel syndrome
Abductor digiti quinti nerve entrapment
Bone bruise
Calcaneal epiphysitis (Sever disease)
Calcaneal stress fracture
Fat-pad atrophy
Heel contusion
Inflammatory arthropathies
Neuropathic pain
Lab Studies
- Lab studies are not needed if plantar fasciitis is suspected. However, laboratory tests may be used to investigate other causes of heel pain if suspected.
Imaging Studies
- Diagnostic imaging is rarely indicated in the initial workup for plantar fasciitis. However, imaging studies may be helpful in defining the extent of the condition or if other etiology are suspected as the cause of the patient's of heel pain.
- Plain radiographs can be used to detect calcaneal stress fractures and other bony lesions.
- Ultrasonography, although rarely used, can aid in the diagnosis of plantar fasciitis. A marked increase in the thickness of the fascia (5-7 mm; normally 2-4 mm thick) may be noted. Other signs seen on sonogram include hypoechogenicity and edema of the fascia where it inserts into the calcaneus as well as loss of definition between the fascia and the surrounding soft tissue.
- Plantar fascia thickening and surrounding edema can also be detected on magnetic resonance imaging (MRI).
Prehospital Care
- ACE wraps may help keep the patient's foot immobilized in case of other injury.
Emergency Department Care
- Medical care in the ED should consist of patient education (see Patient Education) and NSAIDs.
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Nonsteroidal anti-inflammatory drugs are indicated to treat this disorder. They should be used for 2-4 weeks.
Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)
Decrease inflammatory responses and systemically interfere with events leading to inflammation.
| Drug Name | Ibuprofen (Advil, Motrin) |
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| Description | Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Used for analgesia and anti-inflammatory effect. |
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| Adult Dose | 200-800 mg PO q6-8h |
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| Pediatric Dose | 4-10 mg/kg PO q6-8h; not to exceed 50 mg/kg/d |
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| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; acetaminophen/NSAID-induced asthma or urticaria; CABG surgery |
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| Interactions | Coadministration with aspirin increases risk of serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently; may increase lithium levels; may increase nephrotoxicity with ACE inhibitors |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
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| Precautions | Caution in congestive heart failure, hypertension, decreased renal and hepatic function; anticoagulation abnormalities, during anticoagulant therapy, peptic ulcer disease, GI bleeding, corticosteroid use, coagulopathy, asthma |
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Drug Category: Corticosteroids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
| Drug Name | Methylprednisolone (Depo-Medrol) |
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| Description | Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. |
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| Adult Dose | 40 mg intralesionally is typical dose |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular skin infections; joint infection |
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| Interactions | None reported when given as local injection |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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| Precautions | Avoid repeated use; may cause local fat pad atrophy and rupture of plantar fascia; adverse reactions include infection at injection site and postinjection flare |
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Further Inpatient Care
- Inpatient care is usually not necessary.
In/Out Patient Meds
- NSAIDs and ice have been used for symptomatic treatment of plantar fasciitis, although no studies have been done to determine efficacy.
- Corticosteroid injections have been shown to improve symptoms at 1 month but not at 6 months. These injections have been shown to be associated with plantar fascia rupture and fat pad atrophy. These injections should be used conservatively and should probably be left to podiatrists for use, as NSAIDs would be proper first-line management in the ED.
- Autologous blood injection is a treatment option. It is thought that blood injection can help stimulate tendon healing by providing factors that stimulate fibroblast activity and vascular growth. Treatment with autologous blood injection decreased pain and tenderness, but no statistically significant difference was noted between its effects and the effects of corticosteroid injection.1
- Extracorporeal shock-wave therapy (ESWT) has been used to treat plantar fasciitis. Although its efficacy is not definitively proven, it has been approved by the Food and Drug Administration for the treatment of plantar fasciitis and tennis elbow. One meta-analysis found that some studies show favorable results but recommend that it be used only after other noninvasive, proven measures have failed.2 The therapy bombards the tissue with high-pressure sound waves with its mechanism of action being to (1) stimulate blood flow for a beneficial immune response, (2) reinjure tissue to stimulate healing, and (3) shut down the neuronal pain pathways through the pulses hitting the affected nerves.
- Calf stretching has been commonly used but has not been shown to have a statistically significant benefit.3
- Surgery for plantar release (open and endoscopic) has been used in extreme cases that are unresponsive to conservative treatments.
Deterrence/Prevention
- The patient should decrease weightbearing activities (especially running), if possible.
- Shoes inserts (both custom-made orthotics and prefabricated insoles) have been used in conjunction with stretching. No definitive evidence exists that one type of insole is better than another.
- Night splints made to hold the ankle in dorsiflexion and the toe in extension have been used. One Cochrane review found limited evidence in the use of night splints in patients with pain lasting 6 months.4
- Stretching is commonly used, but the exact benefits are unknown. One randomized control trial showed that there was greater improvement in pain with plantar fascia stretching as opposed to Achilles tendon stretching.5
- Casts or splints holding the ankle in neutral to slight dorsiflexion have been investigated, although efficacy is controversial.
Complications
- Risk of plantar fascia rupture and fat pad atrophy exists with steroid injections.
Prognosis
- Eighty percent of cases resolve spontaneously by 12 months. Five percent of patients end up undergoing surgery for plantar fascia release because all conservative measures have failed.
Patient Education
- Wear shoes with adequate arch support and cushioned heels. Discard old running shoes and wear new ones.
- Avoid long periods of standing.
- Lose weight.
- Stretch the plantar fascia and Achilles tendon, especially before participating in exercise.
- Use NSAIDs for pain.
- Do not exercise on hard surfaces.
- Avoid walking barefooted on hard surfaces.
- Avoid high-impact sports, such as aerobics and volleyball, which require a lot of jumping.
Medical/Legal Pitfalls
- Misdiagnosis of other causes of heel pain, such as malignancy or infection, can be a cause of litigation.
- Plantar fascia rupture secondary to corticosteroid injection can cause chronic pain, which can motivate legal action.
| Media file 1:
Plantar fasciitis. Low-dye taping method. The following sketches illustrate the steps involved in low-dye taping, a technique that provides support for the planter fascia and helps reduce excessive pronation. |
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| Media file 2:
Plantar fasciitis. Example of an arch support with a cushioned heel. These are available in three-quarter or full lengths to fit in the shoe. |
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Media type: Photo
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| Media file 3:
Plantar fasciitis. Example of a night splint. These are intended to prevent shortening of the Achilles tendon and plantar fascia at night. |
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Media type: Photo
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- Lee TG, Ahmad TS. Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial. Foot Ankle Int. Sep 2007;28(9):984-90. [Medline].
- Rompe JD, Furia J, Weil L, Maffulli N. Shock wave therapy for chronic plantar fasciopathy. Br Med Bull. 2007;81-82:183-208. [Medline].
- Radford JA, Landorf KB, Buchbinder R, Cook C. Effectiveness of calf muscle stretching for the short-term treatment of plantar heel pain: a randomised trial. BMC Musculoskelet Disord. Apr 19 2007;8:36. [Medline].
- Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev. 2003;CD000416. [Medline].
- DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am. Jul 2003;85-A(7):1270-7. [Medline].
- Atkins D, Crawford F, Edwards J, Lambert M. A systematic review of treatments for the painful heel. Rheumatology (Oxford). Oct 1999;38(10):968-73. [Medline].
- Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J Med. May 20 2004;350(21):2159-66. [Medline].
- Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician. Dec 1 2005;72(11):2237-42. [Medline].
- Hogan KA, Webb D, Shereff M. Endoscopic plantar fascia release. Foot Ankle Int. Dec 2004;25(12):875-81. [Medline].
- Roxas M. Plantar fasciitis: diagnosis and therapeutic considerations. Altern Med Rev. Jun 2005;10(2):83-93. [Medline].
Plantar Fasciitis excerpt Article Last Updated: May 29, 2008
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